Postop complicaition in PACU scenario

[excalibur]

---

Members do not see this ad.

It seems some young guns appreciated the ICU intubation scenario and were asking for more so here goes. Oh, and I just wanted to reply to the young anesthesiologist in training who commented on how I had two shi tty cases in one week. In anesthesiology these cases and scenarios are just part of the biz and in time you will just find them as run of the mill. They still present a challenge but it's just the name of the game.

OK.

Again this is geared more for medical students and jr residents to respond with their plans, but of course I don't want to deny any pearls of wisdom from seasoned vets so feel free.

This scenario is from real life as it happened to me last week...
-----------------------------------------------------------------------------------------------------------------
You are the board runner and are called to the PACU to help manage a patient's HTN. The pt is an 84 y/o man who just had a right carotid endarterectomy this morning. He arrived in the PACU from the OR 10 minutes ago. You notice a PACU nurse holding pressure to the patient's right neck and blood soaked 4x4's around the site. The charge PACU nurse reports that she has already drained 150 mL of blood from the pt's JP drain. She reports the surgeon is aware and he advised the PACU nurses to maintain constant pressure on the surgical site. The pt is alert, in no distress, and responds appropriately. Pt's HR is 59 and BP is 190/100.

Would you treat this blood pressure? Why or Why not?

If so, how would you treat this blood pressure and why?

 

[NightNight]

I'll take a stab

My major concern here is post-op hypertension causing 1) wound hematoma and loss of airway, and 2) hyperperfusion syndrome (my limited understanding is that chronically hypoperfused cerebral vessels distal to the stenosis are maximally dilated and their autoregulation is shot -> can't handle the restored blood flow -> edema and intracerebral hemorrhage). Obviously more concerned about #1 since I think #2 typically occurs much later

So I'm treating this blood pressure, and I want to do it fairly rapidly I think. My guess is IV labetalol or esmolol so I can titrate to effect for SBP and also less risk of rapidly dropping his HR. That being said, I think my first step is an A-line so I can see beat to beat arterial pressures while treating.

So..
1) I want the crash/airway cart at bedside pronto. Maybe the CA(-1) in me talking, but I don't really care that this guy seems fine now, I have no idea how big that neck wound is as I walk up to this scene and by the time he shows me signs of compression on the airway I might have already lost it. I also want equipment for hematoma evacuation readily available.
2) Instruct nurse to keep pressure on the wound, but I'm watching this guy closely for any signs of respiratory distress (tachypnea, agitation, stridor, hoarseness) and checking the wound frequently for expansion (do you still have the nurses perform repeat measurements of the neck for this?)
3) O2 by nasal prongs prophylactically
4) A-line while another nurse grabs meds
5) IV labetalol, titrating to effect, goal SBP.....<150?

 

[excalibur]

Good response. Will give some others a chance to chime in before I proceed with the scenario

 

[fakin' the funk]

Surgeon needs to come to bedside STAT. 150ml from a carotid seems WAY above "normal drainage."

Any specific patient factors or surgical reason to suspect coagulopathy?

The worst thing this could be would be any kind of intracranial hypertensive event (intracerebral hemorrhage, SAH) with compensatory HTN to match the elevated ICP. Sounds like cranial nerve exam is OK though and pt is mentating, yeah?

I'd go with 5 of hydralazine, ready with another 5 then 10, while I dilute up some nitroprusside.

 

[partydoc]

I would be weary to give esmolol/labetalol with a HR of 59. How about hydralazine? Titrate to SBP <160.

 

[Colba55o]

I find Hydral to be a crappy unpredictable drug and in an 84 yr old with CVD, who likely has clogged up cardiac arteries in addition to his clogged up carotids, I worry about reflex tachycardia.

First I'd insist that the vascular surgeons come evaluate
Although I'm worried about hyperperfusion in a newly opened up artery, if he is bleeding that rapidly, I'm not sure how much brain perfusion is actually taking place. I think you have enough time to see what this patients baseline is. If he lives at a HR of 70 and a bp of 120/80 than obviously the approach will be different than he is the typical beta blocked slightly bradycardic but still hypertensive vascular patient

I'd make sure the elevated BP is real, then start a cardipine gtt to get his bp to a high normal range for this patient. If he lives in the 160s SBP I wouldn't want to drop his pressure to 120s abruptly. I like cardene cuz you can bolus it and its easily titrated.

Also make sure there isn't surrepetitious phenylephrine administration occuring

 

[NightNight]

I would be weary to give esmolol/labetalol with a HR of 59. How about hydralazine? Titrate to SBP <160.

I thought about this. Definitely concern for dropping the HR, and that the beta blockade may inhibit reflex tachycardia as well. Why I'm using short acting agents and titrating

I think my major concern about the use of direct vasodilators (nitroprusside, hydralazine), and even nicardipine, is theoretical risk of causing cerebral vasodilation in a patient with newly increased cerebral blood flow and impaired autoregulation

 

[Oggg]

For the oral boards, dont forget to address the ddx of HTN.

 

[aredoubleyou]

Prop, sux, tube.

Not boards, but if he's breathing well, get the airway now. Schedule the case for the surgeon. Get the BP down, his brain will only be affected by bleeding at this point. Benefits of nicardipne > theoretical risks.

 

[Libertas]

the htn/brady is likely because they're mashing on the carotid body holding pressure. secure the airway and open the neck asap.

 

[excalibur]

ORAL BOARD EXAMINER's reply:

You give 5 mg of Hydralazine and call the surgeon. Surgeons states pt is on Plavix, and he is not surprised by the bleeding. He recommends continued pressure at the site. You discover the patient has severe aortic stenosis with a valve area of 0.3.

What are the goals for hemodynamic management in patients with severe aortic stenosis?

 

[NightNight]

ORAL BOARD EXAMINER's reply:

You give 5 mg of Hydralazine and call the surgeon. Surgeons states pt is on Plavix, and he is not surprised by the bleeding. He recommends continued pressure at the site. You discover the patient has severe aortic stenosis with a valve area of 0.3.

What are the goals for hemodynamic management in patients with severe aortic stenosis?

😱

Normal sinus rhythm, heart rate between 70-90, and maintenance of intravascular volume just became really important to me. Atrial kick is this guys best friend.
Now he's post-op, hypertensive, and bleeding - I'm worried about ischemia. I still want to control the hypertension but am doing so carefully because he won't tolerate even a mild degree of hypotension.

Knee jerk responses on rounds for on Neuro consults 😕 someone will have to take me to school on the rest.

*for my future oral board knowledge, when an examiner asks a question like the one above (that seems more generalized) do you answer in the context of the specific patient in question or just answer with your standard severe AS management?

 

[cincincyreds]

It seems some young guns appreciated the ICU intubation scenario and were asking for more so here goes. Oh, and I just wanted to reply to the young anesthesiologist in training who commented on how I had two shi tty cases in one week. In anesthesiology these cases and scenarios are just part of the biz and in time you will just find them as run of the mill. They still present a challenge but it's just the name of the game.

OK.

Again this is geared more for medical students and jr residents to respond with their plans, but of course I don't want to deny any pearls of wisdom from seasoned vets so feel free.

This scenario is from real life as it happened to me last week...
-----------------------------------------------------------------------------------------------------------------
You are the board runner and are called to the PACU to help manage a patient's HTN. The pt is an 84 y/o man who just had a right carotid endarterectomy this morning. He arrived in the PACU from the OR 10 minutes ago. You notice a PACU nurse holding pressure to the patient's right neck and blood soaked 4x4's around the site. The charge PACU nurse reports that she has already drained 150 mL of blood from the pt's JP drain. She reports the surgeon is aware and he advised the PACU nurses to maintain constant pressure on the surgical site. The pt is alert, in no distress, and responds appropriately. Pt's HR is 59 and BP is 190/100.

Would you treat this blood pressure? Why or Why not?

If so, how would you treat this blood pressure and why?

I mean, before treating the BP, assess that airway, cause you may need to secure it before a lawyer gets involved in this case. And tell the POS surgeon to get his rear end into the pacu immediately as I'm not that great with a knife if I have to open up the neck. Also, rule out some causes like hypoxia, hypercarbia, pain, anxiety to see if that is a cause of the HTN. He could also have HTN from carotid sinus injury from the procedure I believe. After going through all these things quickly you probably want to something that acts pretty quickly. I find Nipride is that drug. Really good arterial vasodilator.

Lastly, I would call the cRNA intentsivist to secure the airway. They take a really good online course that tests them on this scenario. Just no training, but he needs practice? Ask the great Allen Iverson.

 

[sucstotherescue]

Of course the patient has AS. Got to love oral boards.

Arotic Stenosis: Patient has inablity to increase CO due to stenosed valve.

#1. Maintain SVR. Patient requires SVR for cardiac perfusion. Thus, we need to find out what this patient's baseline BP is (what others have all ready requested).

For this patient, get A-line. Administer fluids. Do not think 5 mg hydralazine will cause signficant drop in SVR but be prepared with phenyl.

#2. Maintain preload. Patient's require this to maintain SV. Stay away from tachardia, which also increases 02 requirements of heart.

Unlikely patient becomes tachy with 5 mg hydra. However, prepared with b-blockers. I say esmolol.

Get surgery to see this patient. Agree with previous post that 150 cc is still signficant and maintain pressure on site. I am sure I missed something.

On different note thank you excalibur for these scenarios. Your residents are lucky to have. Very happy I found this forum.

 

[partydoc]

ORAL BOARD EXAMINER's reply:

You give 5 mg of Hydralazine and call the surgeon. Surgeons states pt is on Plavix, and he is not surprised by the bleeding. He recommends continued pressure at the site. You discover the patient has severe aortic stenosis with a valve area of 0.3.

What are the goals for hemodynamic management in patients with severe aortic stenosis?

Afterload reduction with the hydralazine. Make sure his tank isn't dry.

 

[VentdependenT]

Hydralazine is crap for this scenerio. cardene is way to go. you want short acting fast on/off drug in bleeding pts

Stroke volume is fixed with severe AS.

To oral board examiner: what were his preop bp's?

 

[excalibur]

😱


*for my future oral board knowledge, when an examiner asks a question like the one above (that seems more generalized) do you answer in the context of the specific patient in question or just answer with your standard severe AS management?

If pt details are given, but then a general question is asked, I fell it's best to give a general response that answers the the general question.

 

[PonyUp]

Wow. Fun case. A lot to learn.

Saw something like this in a child with downs, came into ED s/p tonsillectomy with a carotid dissection.

 

[excalibur]

ORAL BOARD EXAMINER's reply:

After your conversation with the surgeon you re-evaluate the patient. HR 59, BP 110/60. Pt alert and in no apparent distress. The charge nurse states that the blood from the drains has now picked up to 350 mL.

What would you do to manage the patient's continued bleeding?

 

[bkell101]

Did the blood pressure decrease because we treated it? Or is it dropping on it's own?

 

[bkell101]

Whoops missed the 5 of hydralazine part

 

[bkell101]

Did the patient get any heparin intra op at hasn't been reversed?
If he got plavix there's not much we can do about that.
Recheck his inr , platelet counts
Is there hematoma formation around the surgical site?
Identifying why he is bleeding seems like the most important thing here, have the sutures come loose? Leak around the anastamosis? If so, how much blood does that usually lose? Seems like the surgeon needs to evaluate bedside to tell what appropriate.
In the meantime pressure seems like all we can do...surgifoam?

Pardon my ignorance with this post, I really don't know much about the details, but just trying to learn as we go

 

[bkell101]

I'm not positive on this but the platelets in this guy are dysfunctional because he got plavix....I'm thinking transfusing new platelets that work may help

 

[VentdependenT]

I'm not positive on this but the platelets in this guy are dysfunctional because he got plavix....I'm thinking transfusing new platelets that work may help

platelets wont fix this guy. But yes you ttx plavix bleed with them, but the active plavix floating around will just make them useless as well. DDAVP also may help. you can check for DIC if it makes you feel better. PFA checks platelet function. your coags wont tell you this.

Dont let em shut down the OR yet. This dude aint goin to the gen surg ward tonight.

 

[OB1🤙]

Of course the patient has AS. Got to love oral boards.

Yeah but here's the thing- this actually happened. Excalibur texted me after this case, it happened as he laid out.

This is life in private practice, folks. It's all fun and games and chip shots until an oral board scenario blindsides you without warning, and you have to put on the Real Doctor hat they handed you after 8+ years of training and act NOW.

 

[excalibur]

ORAL BOARD EXAMINER's reply:

After your conversation with the surgeon you re-evaluate the patient. HR 59, BP 110/60. Pt alert and in no apparent distress. The charge nurse states that the blood from the drains has now picked up to 350 mL.

What would you do to manage the patient's continued bleeding?

OK. So you start a fluid bolus and are ordering a stat CBC, when the nurse calls you back to bedside. The pt's HR is 34 bpm and BP on art line is 45/15. Nurse reports that the bleeding is now at 650 mL. Pt is still awake and answering your questions saying he feels fines. The PACU nurses have contacted the surgeon again who says he is on his way.

What would you do?

 

[bkell101]

Now i have very limited experience but ive seen a handful of folks with those vitals and they all looked like hell .....With those vitals I can't believe he is feeling fine and talking! Something doesn't add up

...maybe this guy is moments away from going down hill fast......

It's its hypovol shock from blood loss, then why isn't his hr responding? Kinda makes me think something else is going on....what does the telemetry show? The last two Brady hypotensive guys I saw we're RCA infarcts involving the node ...,then again this is a vascular case that was working near the carotid sinus....I'll have to review but something makes me think this is the source

Either way .....if the vitals are real....

Get the crash cart...pads on....unstable Brady calls for atropine. May even have to externally pace?

Get ready for push dose epinephrine if his bp doesn't improve

Tell the nurse to wide open fluids and mix up either dopa/Levo which ever is faster

Do we have good access yet? If not get a central in the groin. May want to call for another hand in case he crumps and airway has to be taken care of prior to getting access

Have somebody update the surgeon and let him know to get there in a hurry

 

[VentdependenT]

OK. So you start a fluid bolus and are ordering a stat CBC, when the nurse calls you back to bedside. The pt's HR is 34 bpm and BP on art line is 45/15. Nurse reports that the bleeding is now at 650 mL. Pt is still awake and answering your questions saying he feels fines. The PACU nurses have contacted the surgeon again who says he is on his way.

What would you do?

Juicy!

check bp in other arm. dude shouldnt be perfusing his noggin with that bp.

Who said hydralazine? poor choice.

650ml loss with crap BP? Cardiogenic.

Barorecptor messed up. Stat ekg. Throw US on chest (heart n lung) and neck. Check MB and istat.

Agree with atropine slug (if it dont work then AV node toast). Start levophed. Fluid. access.

Someone needs to hold FIRM pressure.

Back to OR

 

[bkell101]

I'm wondering if the plaque and disease in the carotid has changed the set point of the baroreceptor ....if you take out the plaque and now have sudden increased stretch the barro receptors fire more (parasympathetic drive) ....then bradycardia hypotension ensue?

 

[excalibur]

Juicy!

Haha! Not sure why but this made me laugh, Venty. I can assure you that in the moment, I did NOT find that abrupt change juicy! 😉

ORAL BOARD EXAMINER's reply:

You give atropine and the HR Is now 55 bpm and BP 94/61. Pt remains alert. Nurse informs you that she is no longer draining blood into the JP, and she suspects the drain has clotted off. You inspect the neck, and the right neck is considerably more swollen than the left. Pt is breathing comfortably and currently in no respiratory distress.

What would you do if the patient suddenly started becoming dyspneic and O2 saturation started decreasing?

 

[bkell101]

Haha yeah that juicy comment was funny and totally threw me off

I'm worried the pt is developing a hematoma and subsequent upper airway obstruction.

Get ready to intubate....I think this may need to be pretty fast ......induction meds....ketamine or etomidate (given my vitals) + sux ...make sure to have a smaller tube ready and trach kit..i would tell somebody to call the surgeon and get ready to go back to the or for exploration.


If somebody has impending airway obstruction below the level of the cords...how do u know If you aren't going to be able to bypass with the tube...just put it past the cords and if you meet resistance early time to go to trach? Are you allowed to try and put much force behind the tube, or is there a chance of perforating something?

Maybe somebody should be opening the trach kit while I try with the tube just to avoid wasting time

 

[excalibur]

Other replies? Seasoned vets care to chime in with pearls of wisdom?

 

[VentdependenT]

Hematoma pushing into pharynx and larynx. needs urgent airway stabilization then decompression of hematoma. "Awake" FOI. Could try and suck some blood out of neck, but that blood is probably tamponading the source to some degree. I am a cowboy but im not a surgeon.

Whatever airway patency that remains may become obliterated with loss of pharyngeal tone so i would avoid inducing.

 

[NightNight]

Hematoma pushing into pharynx and larynx. needs urgent airway stabilization then decompression of hematoma. "Awake" FOI. Could try and suck some blood out of neck, but that blood is probably tamponading the source to some degree. I am a cowboy but im not a surgeon.

Whatever airway patency that remains may become obliterated with loss of pharyngeal tone so i would avoid inducing.

Don't want to derail the thread, but this part of the case really intrigues me. To all the attendings/vets, what is your absolute threshold for taking a scalpel/sterile scissors to the hematoma/suture line in this situation? What combination of worsening clinical status/can't establish secure airway/closest surgeon is miles or minutes away compels you to pick up the steel?

 

[Mman]

Other replies? Seasoned vets care to chime in with pearls of wisdom?

He needs...

1) airway controlled

2) BP controlled (that can be done at the same time as #1, but is a distant 2nd concern and should not trump airway control)

3) surgical site exploration


Now if during intubation attempt anatomy is distorted you might need someone to pop some sutures from the wound to release pressure so I'd personally have the surgeon standing close by.

Once the tube is in, you control the situation pharmacologically until a surgeon can correct the anatomical problem.

 

[Laryngophed]

Haha! Not sure why but this made me laugh, Venty. I can assure you that in the moment, I did NOT find that abrupt change juicy! 😉

ORAL BOARD EXAMINER's reply:

You give atropine and the HR Is now 55 bpm and BP 94/61. Pt remains alert. Nurse informs you that she is no longer draining blood into the JP, and she suspects the drain has clotted off. You inspect the neck, and the right neck is considerably more swollen than the left. Pt is breathing comfortably and currently in no respiratory distress.

What would you do if the patient suddenly started becoming dyspneic and O2 saturation started decreasing?

Just an M3, so excuse me if I know nothing.

If the patient starts to desat, you have to get control of that airway. This screams hematoma that isn't going to resolve and you'd like to save this guy from a crich/trach if possible. I think that combined with his instability means he's going back to the OR. If the JP isn't draining anymore, and you've got 2/3s of a liter through it, it being clotted off isn't unreasonable. And if the blood isn't getting into the JP, it has to be going somewhere.

Call the surgeon, tell him to find an OR because you and your newly (re-)intubated* friend are returning to the OR and he needs a stat dissection/rexploration of that neck.


*Maybe re-intubation is too drastic a step at this point, I'm not sure. But given my dearth of knowledge, I can only fall back on ABC. When he starts desatting/feeling dyspneic, I can only assume I am physically about to lose the airway until I can prove otherwise. If it was available, an U/S over the neck to look for hematoma formation would be helpful, but I have yet to see a spare U/S just chillin' in the PACU.

ETA - From what I have read/remember etomidate is on my short-list of go-to induction meds because it is less likely to decrease CO. In this guy, I'm guessing that the 2/3s of a liter we've seen aren't all of it, so I have a low threshold to transfuse in the setting of dyspnea/desat in someone who is actively bleeding and has no way to increase CO.

 

[anes]

He needs...

1) airway controlled

2) BP controlled (that can be done at the same time as #1, but is a distant 2nd concern and should not trump airway control)

3) surgical site exploration


Now if during intubation attempt anatomy is distorted you might need someone to pop some sutures from the wound to release pressure so I'd personally have the surgeon standing close by.

Once the tube is in, you control the situation pharmacologically until a surgeon can correct the anatomical problem.

Agreed.

 

[excalibur]

ORAL BOARD EXAMINER's reply

The surgeon arrives before any problems with dyspnea. He assesses the situation and sees the neck swelling. He agrees the patient needs to go back to the OR for exploration.

How would you induce anesthesia in this patient?

 

[Oggg]

No one wants to have the surgeon just open the wound to let the hematoma decompress (awake)?

 

[bkell101]

No one wants to have the surgeon just open the wound to let the hematoma decompress (awake)?

That was going through my head when I originally responded, but then I was reading the ruptured aaa thread and people were talking about cutting into the belly and pt going down fast because of the release of the tam pomade....the pressure is probably different in the neck though....

If this thing is bleeding rapidly and I cut into the neck without the surgeon there.....the airway obstruction will likely decompress but now I have a whole new problem on my hand ....how do I stop the bleeding (aside from putting pressure over it and recreating the closed compartment all over again)?

 

[bkell101]

I like vents concern about losing muscular tone and further compromising airway....

Makes me just want to try to get a smaller tube in over a fiber optic scope with the patient awake.

If the airway is a pinhole then have a partner make a slit in the neck, decompress just enough to get the tube past, reapply pressure, hope like hell the surgeon gets here soon.

Btw way I'm very interested to find out the right / sensible way of dong this....b/c I'm sure I'm way off

 

[partydoc]

Juicy!

check bp in other arm. dude shouldnt be perfusing his noggin with that bp.

Who said hydralazine? poor choice.

650ml loss with crap BP? Cardiogenic.

Barorecptor messed up. Stat ekg. Throw US on chest (heart n lung) and neck. Check MB and istat.

Agree with atropine slug (if it dont work then AV node toast). Start levophed. Fluid. access.

Someone needs to hold FIRM pressure.

Back to OR

Hey vent, mind explaining why hydralazine sucks in this situation?

 

[Laryngophed]

Hey vent, mind explaining why hydralazine sucks in this situation?

He alluded to picking agents with short t1/2s. Hydralazine lingers for hours, nifedipine has a shorter half-life.

 

[VentdependenT]

Hey vent, mind explaining why hydralazine sucks in this situation?

Hydralazine lasts 4-6 hr and takes 20min to peak. Why the hell would i want to push a long acting vasodilator in a pt whom I concerned about bleeding. you can get into trouble this way. Now the dude is going back to the OR, probably a liter down, with a long acting vasodilator on board, hypotensive...

Hydralazine has its place, put periop use should be limited to stable pts whom have primary htn.

I generally dont give 2****s about bp unless its low or SBP acutely >190 or dias >110.

 

[Agast]

No one wants to have the surgeon just open the wound to let the hematoma decompress (awake)?

You don't know what the source of the active bleeding is and he just did a CEA. I would hesitate to do anything surgical at the bedside, the surgeon needs to be able to get good exposure/visualization and sterile instruments to quickly control what might be arterial.

 

[excalibur]

You don't know what the source of the active bleeding is and he just did a CEA. I would hesitate to do anything surgical at the bedside, the surgeon needs to be able to get good exposure/visualization and sterile instruments to quickly control what might be arterial.

So can the above not be accomplished with the patient awake?

 

[bkell101]

So can the above not be accomplished with the patient awake?

I think I read superficial and deep cervical plexus block are what's used to do cea awake.

The first case I ever saw in the or from anesthesia side was an awake cea (the resident asked if i wanted to try to intubate. i was so nervous i forgot to put gloves on when we went into the room. The resident and attending didnt notice until they were about to let me mask ventilate...when they saw my hands, I forgot what they said but it was along the lines of get the hell out of here if you don't even know to put gloves on....hahaa I'll never forget that)

Anyways, illI have to read more about how to do them, but with a hematoma distorting the anatomy I think It might be tough

 

[bkell101]

Is local an option?

 

[excalibur]

I think I read superficial and deep cervical plexus block are what's used to do cea awake.

The first case I ever saw in the or from anesthesia side was an awake cea (the resident asked if i wanted to try to intubate. i was so nervous i forgot to put gloves on when we went into the room. The resident and attending didnt notice until they were about to let me mask ventilate...when they saw my hands, I forgot what they said but it was along the lines of get the hell out of here if you don't even know to put gloves on....hahaa I'll never forget that)

Anyways, illI have to read more about how to do them, but with a hematoma distorting the anatomy I think It might be tough

Why were you going to intubate a patient that was going to have an awake CEA?

 

[bkell101]

Why were you going to intubate a patient that was going to have an awake CEA?

? I don't understand ....I think I'm confused to what you are referring to or where we are in the case...


But as I rethink the scenario with the expanding hematoma,

Original cea was awake + airway isn't yet compromised + surgeon is there = make sure our block is still working, go to OR and not have to induce